Decannulation

Sydney examines her trach tube just after decannulation.

Decannulation - The removal of a cannula: in the case of children with trachs, the
removal of the tracheostomy tube. Decannulation depends on the reason for the trach tube
and the course of treatment for the particular diagnosis or condition for which the trach
tube was placed. Once the reason for the tube is resolved, decannulation can be attempted
(usually is a hospital setting under the care of an otolarnygologist). For most children,
a tracheostomy is temporary. The child may outgrow the problem or the problem
can be surgically corrected.

Simply remove the tube. If the stoma (hole) does not close by itself, a minor surgical
procedure may be needed.

Place a smaller tube and plug the tube for increased amounts of time. When the child is
tolerating the plug 24 hours a day, then the tube can be removed.
Note: A speaking valve may be used as a transitioning tool between an
open trach tube and plugging for decannulation. This allows for the
child to transition to using the upper airway for exhalation, reintroducing
airflow and sensation and easing the anxiety often associated with plugging.

Include the decannulation as part of a reconstructive procedure

Surgical decannulation (when repair of the trachea around the tube is needed).

Sleep studies in the hospital setting are often ordered after downsizing or with trach
capped to be sure apnea is not present.

Accidental Decannulation

"The following discussion describes a general approach to patient management,
and is not meant to recommend treatment for any specific patient. Every patient is
different, and requires the personal attention of his or her own health care
provider."

There are essentially two reasons for a tracheotomy tube: lung disease and airway
obstruction. Patients with lung disease may need the tube for attachment to a mechanical
ventilator or to allow suctioning of secretions. Patients with obstruction may have
narrowing of the airway between the vocal cords and the tube (such as subglottic stenosis)
or have collapse of the throat above vocal cords (such as severe obstructive sleep apnea).

At some point, the condition for which the tube was placed may have resolved, and
decannulation (removal of the tube) is desired. If the tube was placed for airway
obstruction, it is typical to give the patient a "dry run" by putting in a
smaller tracheotomy tube ("downsizing") and plugging it for a period of time.
This allows the patient to breath normally through the nose and mouth, around the plugged
tube. If the obstruction has not sufficiently resolved, or if there is new obstruction
related to the tube itself (such as a granuloma or collapse- see below) the patient can
easily be unplugged at any time, maintaining a safe airway. This is commonly done after
surgery to treat the primary obstruction, such as laryngotracheoplasty to expand a
stenotic subglottis, or surgery on the upper throat (e.g.
uvulopalatopharyngoplasty) to
treat obstructive sleep apnea. Once a period of healing has taken place and the surgical
swelling has resolved, the patient may be slowly and safely moved towards decannulation in
this fashion.

Other patients with airway obstruction may have narrowing that extends down to the
tracheotomy site itself, requiring reconstruction of the trachea right next to the
tracheotomy tube. In this case, or in other cases of less severe subglottic stenosis, a
single stage laryngotracheoplasty may be performed. This operation combines the expansion
of the narrow airway and the removal of the tube into one procedure, so there is no
separate decannulation. Of course, this is somewhat riskier, since if the expansion is
unsuccessful, there is no tracheotomy tube in place to secure a safe airway, and the
patients may need an emergency intubation or replacement of the tracheotomy itself.

If decannulation is planned after ensuring that the airway is sufficiently enlarged, or
if the lung disease has resolved, there are several options. In adults- especially those
who have had their tracheotomy tubes for relatively short periods of time- the tube may be
simply removed and the hole allowed to close by itself. This generally happens in a few
days. If the tube has been present for a long time, the hole may not close completely, and
a small pinhole may be left after a month or so. This may then require a small procedure
to remove the skin lining the tract (which prevents closure) and allow the hole to close.

In all patients with a tracheotomy, the tube pushes on the trachea immediately above
the hole, causing the front wall of the trachea to collapse into the airway above the
tube. This is known as "suprastomal tracheomalacia". Also, most patient with
tracheotomy tubes have a suprastomal granuloma- a small mass of inflammatory tissue above
the tracheotomy site- that the body produces in response to the foreign body (the tube).
For older children or adults, the collapse and the granuloma represent small percentages
of the airway diameter and should not complicate decannulation. For smaller children, the
collapse or the granuloma may be enough to prevent decannulation, even if the primary
reason for the tracheotomy has been successfully treated. In such cases, "surgical
decannulation" may be necessary. This operation involves placing a breathing tube
(endotracheal tube) through the nose or mouth after removing the tracheotomy tube,
removing the skin lining the path of the tube, removing the granuloma, and then suturing
the collapsing front wall of the trachea forward to allow healing of the tube site. The
patient is kept in an intensive care unit, and the endotracheal tube is removed after a
day or two.